Affirmative Action

Voluntary Information

Completion of information below is voluntary.

We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.
To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application. In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated. Please be advised that this survey is not part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations.

Please print

Position(s) applied for	Date:
Referral Source
Walk-in	Government Employment Agency	Private Employment Agency
Employee	Relative	School
Advertisement—Source	Other
Name of person who referred you (if applicable)

Applicant Information

Name:	Telephone:
Last	First	M.I.
Address:
Street Address	City	State	Zip Code

Gender:	Male	Female

Please check one of the following Equal Employment Opportunity Identification Groups:
☐ White (not of Hispanic origin)	☐ Black (not of Hispanic origin)	☐ Hispanic
☐ American Indian/Alaskan Native	☐ Asian/Pacific Islander	☐ Multiracial (having parents of different races) This identification group is recognized only in the state of Michigan.

For Administrative Use Only

Position(s) applied for	Available	Not Available
Other positions considered for
Hired	Yes	No
Position hired for	Date of Hire